Devon Road Surgery Also known as Drs Aburn, Auckloo & Von Fraunhofer

We carried out an announced inspection at Devon Road Surgery. We conducted remote clinical searches on the practice’s computer system on 11 July 2022 and conducted an onsite inspection of the practice on 12 July 2022 under Section 60 of the Health and Social Care Act 2008, as part of our regulatory functions.

The key questions at this inspection are rated as:

Safe - Good

Effective - Good

Responsive - Good

Well-led – Good

Overall, the practice is rated as Good.

Following our previous inspection on 22 November 2016, the practice was rated Good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Devon Road Surgery on our website at www.cqc.org.uk.

Why we carried out this inspection

This inspection was a focused comprehensive inspection to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection focused on the following:

• Are services safe?
• Are services effective?
• Are services responsive in relation to access?
• Are services well-led?

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting staff interviews using video conferencing
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider
• Reviewing patient records to identify issues and clarify actions taken by the provider
• Requesting evidence from the provider
• A short site visit

Our findings

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall.

We found that:

• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
• The practice had clear systems and processes to keep people safe and safeguarded from abuse.
• Appropriate standards of cleanliness and hygiene were met.
• Staff had the information they needed to deliver safe care and treatment.
• The provider learned and made improvements when things went wrong.
• There was compassionate and effective leadership at all levels.
• The practice had a programme of targeted quality improvement and used information about care and treatment to make improvements.
• The practice had systems in place to continue to deliver services, respond to risk and meet patient’s needs.
• There were systems and processes for learning and continuous improvement.
• Staff had the skills, knowledge and experience to carry out their roles. However, some staff had not received fire marshal.
• Systems for managing safety alerts were not always effective.
• Improvements were needed for the process of monitoring patients’ health in relation to the use of high-risk medicines and long-term conditions,
• Improvements were required in relation to the management of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms.

Whilst we found no breaches of regulations, the provider should:

• Continue with their action plan to ensure ongoing improvement in relation to; the safe management and monitoring of high-risk medicines and patients with long-term conditions
• Ensure staff are up to date with training.
• Continue efforts to restart formal meetings with members of the patient participation group.
• Continue with and embed the policy of retaining copies of DNACPR forms on the patient’s records, where there is one in place.
• Consider appointing a Freedom to Speak Up Guardian.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care